Objective: The seasonal relationship of incidence of musculoskeletal system (MSS) pathologies according to gender and their meteorological variability has not been investigated satisfactorily. The aim of this study is to determine diagnostic distribution of patients with MSS-related complaints and the seasonal relationship of these diagnoses. Materials and Methods: This study was conducted on 45541 patients having MSS-related complaints. Female/male ratios of eleven diagnosis groups were considered and monthly/seasonal incidences were evaluated and relations with climatic factors were searched. Results: While number of patients for both genders admitted to polyclinics increased more in winter, lowest number of patients were admitted in summer. While knee-related pathologies were increased in April (9.4%) and rheumatologic disorders were increased in September (13.3%) for female patients, lumbar pathologies were most frequent in December (9.6%) and rheumatologic disorders were most frequent in September (13.0%) for male patients. Negative correlation was found between average temperature and knee pathologies for all the patients (r=-0.952, p=0.048). There were positive correlations between humidity and knee (r=0.980, p=0.020), elbow (r=0.951, p=0.049), hip (r=0.957, p=0.043), hand-wrist (r=0.963, p=0.037) and pathologies requiring rehabilitation (r=0.954, p=0.046). Conclusion: The number of admissions increased for both genders in winter months, and decreased in summer months. Moreover, relationships of some MSS pathologies with seasonal/meteorological changes should be considered.

Introduction

Musculoskeletal system (MSS) disorders are a group of diseases characterized by pain, limitation of movement and impairment in structure and function of MSS (1). Although MSS disorders consist of a large group of diseases in pathophysiological aspect, they meet at a common point, since they all lead to pain and reduction in physical functions (2). MSS disorders are among the most common diseases in the community. MSS disorders, which hold a significant place among causes for admission to health facilities, also have importance for their burden on quality of life (QOL) and the national economy. MSS disorders are important public health issues, which affect entire age groups and genders, creating disabilities and loss of power (3). In developed countries, bone and joint problems have been reported to constitute half of all chronic disorders in patients aged 50 years and over (4). Although MSS disorders are not fatal, they reduce the QOL and economic productivity (3). World Health Organization, within the scope of a project, suggested all countries to follow and report the prevalence of findings and diseases related to MSS, together with their causes, for early diagnosis and particularly for prevention of complications and additionally, declared the 2000-2010 years as the bone and joint decade. In the literature, there have been very few studies on the relationship of prevalence of MSS disorders with months and seasons and they were performed with limited number of disorders. For example, in the study on 2030 workers conducted by Hildebrandt et al. (5) in 2002, the relationships of lumbar, neck and shoulder pain with climate were investigated and poor climatic factors and particularly air currents and wind were found to be triggering factors for MSS pathologies such as lumbar region, neck and shoulder. One aim of our study was to investigate the diagnostic distribution of patients who had presented to our outpatient clinic with musculoskeletal symptoms according to their genders and also the relationships with months and seasons according to these diagnoses. Another aim was to assist planning of the health services with obtained data.

Materials and Methods

This study was conducted retrospectively on a total of 45541 patients who had presented with MSS complaints to the department of physical therapy and rehabilitation outpatient clinics over two years, between the dates of January 1st 2013 and December 31st 2014. The study was approved by the Local Ethics Committee of Atatürk University (Protocol No: 01/24.10.2016). The musculoskeletal pathological diagnoses were based on clinical, laboratory and radiological findings and they were classified and grouped as neck-back, lumbar, shoulder, elbow, hand-wrist, hip knee and foot-ankle pathologies, rheumatologic disorders, osteoporosis, central and peripheral nervous system (PNS) disorders necessitating rehabilitation. No inclusion criteria was regarded for pain characteristics of the patients such as the duration, frequency, intensity (mild, moderate, intense, severe, etc.) and quality of the pain (continuous, intermittent, etc.) in the classified regions mentioned above, except only existence of pain in these regions was considered in this study. Data on gender and diagnoses of the patients were acquired from the hospital computer records. The recurrent admissions of any patient were evaluated as new admissions. The prevalence’s of the diagnostic groups were evaluated in terms of months and seasons, taking the numbers and ratios of female and male patients into consideration. December, January and February were considered as winter, March, April and May as spring, June, July and August as summer, September, October and November as autumn. The analysis of months and seasons were made separately, according to diagnostic groups. Additionally, with the purpose of revealing the relationship of months and seasons with some environmental conditions, meteorological data such as average weather temperature, humidity, atmospheric pressure and wind speed of the region were used. The data used in the study were evaluated, which were demanded officially from the 12th Regional Directorate of Meteorology. The descriptive statistics for the distribution of diagnostic groups analyzed in this study in terms of gender, months and seasons was performed using Statistical Package for Social Sciences for Windows 20.0 statistical software package. The relationships of diagnostic groups, gender, months and seasons were evaluated using correlation and chi-square analysis. Pearson’s correlation coefficient analysis was used to observe the relation ship between the climatic factors (weather temperature, humidity, atmospheric pressure and wind speed) and diagnostic groups. The significance level was established as a p-value <0.05.

Results

A total of 45541 patients were subjected to evaluation, of whom 29960 (65.8%) were female and 15581 (34.2%) were male (p0.05). In male patients, while lumbar pathologies increased in December (9.6%), they decreased in October (6.9%). Rheumatologic disorders increased in September (13.0%) and patient admission were observed to be reduced in October and December (5.2%). The other disease groups reached their highest levels in January. The lowest levels for admission rates were in June for neck pathologies (7.1%), in November for osteoporosis patients (2%), and in October for other pathologies (Table 1). In male patients, while the monthly distributions of lumbar, knee, osteoporosis and rheumatologic disorders (p0.05). When the seasonal distributions of the diagnoses were analyzed; in male patients, the seasonal distributions of neck, back (p0.05). In female patients, while seasonal distributions of lumbar, neck, osteoporosis, rheumatologic disorders (p0.05). When various climatic data such as monthly average temperatures, humidity, wind speed and atmospheric pressures in 2013 and 2014 were analyzed; the hottest month was August, the coldest was January; the highest humidity was in December, the lowest was in August; the highest wind speed was in May, the lowest was in February; the highest atmospheric pressure was in October and December, the lowest was in March (Table 2). When seasonal averages were taken into consideration; the hottest season was summer; the highest atmospheric pressure was in autumn; the highest humidity was in winter; the highest wind speed was in spring (Table 3). Regarding monthly average values of various climatic factors such as temperature, humidity, average atmospheric pressure and average wind speed and diagnostic groups; in female patients, while there were negative correlations between temperature and hip (r=-0.580, p=0.048) and foot-ankle pathologies (r=-0.578, p=0.049), positive correlations were determined between humidity and neck-back (r=0.612, p=0.034), shoulder (r=0.613, p=0.34), elbow (r=0.620, p=0.031), hand-wrist (r=0.622, p=0.031), hip (r=0.611, p=0.035), foot- ankle (r=0.627, p=0.029) and rehabilitation patients (r=0.609, p=0.036). No correlation was determined between pathologies and atmospheric pressure, average wind speed (p>0.05). In male patients, no relationship was found between diagnoses and monthly average temperature, humidity, atmospheric pressure and average wind speed (p>0.05). When all patients were taken into consideration, negative correlations were determined between monthly average temperatures and neck-back (r=-0.626, p=0.029), shoulder (r=-0.607, p=0.036), elbow (r=-0.615, p=0.033), hand-wrist (r=-0.623, p=0.030), hip (r=-0.613, p=0.034), foot-ankle (r=-0.616, p=0.033) and central nervous system (CNS) and PNS pathologies necessitating rehabilitation (r=-0.612, p=0.034). Positive correlations were determined between humidity and neck-back (r=0.674, p= 0.016), shoulder (r=0.658, p=0.020), elbow (r=0.664, p=0.018), hand-wrist (r=0.678, p=0.015), hip (r=0.649, p=0.022), knee (r=0.596, p=0.041), foot-ankle (r=0.667, p=0.018) and CNS/PNS pathologies necessitating rehabilitation (r=0.653, p=0.021). No relationship was determined between diagnoses with average wind speed and atmospheric pressure (p>0.05) (Table 4). In female patients, no relationship was found between diagnoses and average seasonal temperature, humidity, wind speed, atmospheric pressure (p>0.05). In male patients, positive correlations were determined between seasonal average humidity values and neck-back (r=0.985, p=0.015), shoulder (r=0.967, p=0.033), elbow (r=0.963, p=0.037), foot-ankle (r=0.963, p=0.037), hip (r=0.976, p=0.024) and CNS/PNS pathologies necessitating rehabilitation (r=0.965, p=0.035). No relationship was found between other pathologies with temperature, wind speed and atmospheric pressure (p>0.05). When all patients were taken into consideration, a negative correlation was found between average temperature and knee pathologies (r=-0.952, p=0.048). Positive correlations were determined between humidity and knee (r=0.980, p=0.020), elbow (r=0.951, p=0.049), hip (r=0.957, p=0.043), hand-wrist (r=0.963, p=0.037) and CNS/PNS pathologies necessitating rehabilitation (r=0.954, p=0.046). No relationship was found between diagnoses with average wind speed and atmospheric pressure (p>0.05) (Table 5). In addition, considering all the patients, male or female, no relationship was found between the rheumatologic disorders and climatic parameters such as monthly and seasonal average temperature, humidity, atmospheric pressure and wind speed (p>0.05).

Discussion

The most common complaint for presentation of patients with MSS pathologies to the clinicians is pain. Pain is more prevalent in certain patient groups. In a general community survey, 80% of the population, aged between 15-84 years, was determined to have MSS symptoms, in 13% of which the pain was severe. MSS problems are seen more frequently in females, when compared to males (6). In our study, being consistent with the literature, number of female patients was found higher than number of male patients in all months and seasons. Hormonal factors, higher level of sensitivity to pain and weaker strength of muscles and tendons of the female patients may be possible reasons for this finding (7). In the literature, MSS pain is most frequently observed at the lumbar region and it is within the chronic disorders, which restrict daily activities of people (8). The second most frequent complaint following low back pain in patients presenting to pain clinics is neck pain (9). Neck pain is more common in females than males (10). In the community, shoulder pain is in the third place, following low back pain and neck pain (11). However, in the elderly age group, knee pathologies have been reported to be second most common, following lumbar pathologies (12). In female patients, the prevalence of diagnostic groups, which were consistent with the literature, were determined to be lumbar region, knee, neck, rheumatologic, shoulder, rehabilitation, elbow, foot and ankle, hip, osteoporosis, hand and wrist pathologies in order of frequency, whereas in male patients, the diagnostic group of rheumatologic pathologies was in the third place, before neck pathologies. The knee pathologies being the second most frequent diagnostic group in our study might have been due to particularly the incidence of degenerative diseases being high in our region, the average age of our patient group being middle-age and higher, our patients being over-weight and their exposure to chronic trauma. In our study, while the number of female patients showed the highest increase in November, in which the temperatures averaged 2.7 °C in our region, which had humidity value above the yearly average, and had a high average value of atmospheric pressure, it showed a significant decrease in July, in which high temperature was dominant, and humidity and atmospheric pressure had their lowest levels (p0.05). One of the significant results in our study was the incidence of osteoporosis being 90% in females and 10% in males, which was consistent with the literature. When the monthly distribution of patients with osteoporosis was evaluated, in female patients, the number of admissions was found to be highest in February (12.7%) and January (11.8%) and significantly lower than the other months in October (3%) and July (4.6%). In male patients, the highest number of admissions was in January (24.2%) and the lowest numbers were in November (2%) and September (3%). However, no significant correlations were found between number of admissions and various climatic data such as weather temperature, humidity, atmospheric pressure and wind speed (p>0.05). According to the literature, serum 25 vitamin D [25(OH)D] level shows seasonal variations and reaches its highest level in summer (26,27). Additionally, in a conducted study, serum 25(OH)D level was found to be statistically significantly higher in late summer, when compared to the level in late winter and also, bone resorption markers such as pyridinoline and deoxypyridinoline were found to have their lowest levels in late summer, showing seasonal variations (27). However, similar to our study population, insufficient vitamin D levels were associated with advanced age, female gender, high latitudes, winter season, dark skin color, living in indoor environment and clothing style (28). There are variations in the prevalence of osteoporosis patients’ apply to hospital according to seasons and months. However, it should also be known that there exists social, medical reasons and many biochemical parameters including 25(OH)D vitamin the levels of which we did not look in.

Conclusion

Consequently, in both genders, the number of MSS pathologies increase in winter whereas it decreases in summer. In female patients, while there positive middle level correlations were determined between humidity and neck-back, shoulder, elbow, hand-wrist, hip, foot- ankle and rehabilitation patients. In male patients, positive very high correlations were determined between seasonal average humidity values and neck-back, shoulder, elbow, foot-ankle, hip and CNS/PNS pathologies necessitating rehabilitation. In females, humidity showed positive correlation at medium levels with neck-back, shoulder, elbow, foot-ankle, hip and rehabilitation patients. In males, mean seasonal humidity values showed significant positive correlations with neck-back, shoulder, elbow, foot-ankle, hip and CNS/PNS pathologies necessitating rehabilitation. Therefore, in order to avoid these pathologies, it may be beneficial to stay away from excessive cold and humidity. Rheumatologic pathologies and osteoporosis patients do not have any correlations with climatic data such as weather temperature, humidity, atmospheric pressure and wind speed. Therefore, the investigated climatic factors are not effective in these pathologies. It is thought that more comprehensive studies are needed, which will investigate the relationship between the disease and climatic changes and which will be conducted in a wider geographical region with different climatic characteristics and a different altitude. Our study is not free from limitation. We found that the monthly and seasonal disease percentages have been correlated with climatic conditions. But, other potential conditions such as social or medical conditions of the patients may also have an influence on patients’ applications to hospitals. However, primary aim of this study was to assess distributions of musculoskeletal symptoms in monthly and seasonal basis. Possible effects of social or medical conditions of the patients may be subjected to another study. In addition, reasons of an increase in number of the osteoporotic patients during winter and a decrease in number of the osteoporotic patients during winter must be evaluated with biomarker studies in future. Ethics Ethics Committee Approval: The study was approved by the Atatürk University of Local Ethics Committee (Protocol No: 01/24.10.2016), Informed Consent: Consent form was filled out by all participants. Peer-review: Internally peer-reviewed. Authorship Contributions Surgical and Medical Practices: A.K., M.U., Concept: A.K., M.U., Design: A.K., M.U., Data Collection or Processing: A.K., M.U., Analysis or Interpretation: A.K., M.U., Literature Search: A.K., M.U., Writing: A.K., M.U. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support.